30057 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMUTING, F7
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, OOV 1
BUILDING PROJECT IDENTIFICATION
BUILDING gDD%BSS: j SANITARY NO. APPLICATION SUBMITTAL DATE
7c
s� OWN. SNAMG PHONE: "im CO CTON'S NA7. ♦', / L O: ON�_•
M4:4 R
[/ NIC CONTROLN
ARCHITECT/ENGINEER: LICNO: ADD 'S: a le- ❑ -
' 4L S. J—C4
CONTACT: PHONE: I - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initlal) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE
1 hereby affirm Ndi I rte licensed under provisions of Chapter 9(commencing JOB,DESCRIPTION
X00 with Section 7")of Division 3 ofthe Bumrssand Prof ssinns Co de.undmylicenseie
00 PERMIT ISSUANCE - RESIDENTIAL: . '
y�lU� full force and eR I [/
yQ� License Cla. Z Lina ❑ADWL ❑PLUM FN REMODEL
Date 'Commnnr APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RF.-PIPE
t„p•y•� AR 1 CPS .0 RATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
ZOyq Iva my plan e x is records MODIFICATION
OZ� UP T0200)AMPS '
NNO - - ❑INTERIOR CHIMNEY REPAIR
T.. Licensed Professional. 20M000AMPS IMPROVEMENT,
�4` OWNER-BUILDER DECLARATIONOVER 1000 AMPS, [j BATH RF.MODEUREPAIR 0 DEMOLITION
y 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
pd a 6 U following arson(Section 7031.0.Business and Professions Cale:Any city or county SIGNS ELECTRICAL []OTHER
which requires a permit re construct,alter,improve,for such
demolish,or repair my structure - A/'/0
prior toslts cense ce,also parmoreyuires the applicant CcIhpemsit toicensle ae aw(statement SPECIAL CIRCUIT/MISC. g
6E Nat me cing wit pursasm7 Ne provisions of the Contractor'snd ProelawlChapter9
YG (cat he
iagwiNSection]fl0f)of Divisions oft he Business and Professionsium of TEMP.METER OR POLE INSTCOMMERCIAL,BL
d y N that he is exempt Iherefmm end the basis for 1n ersallegedbxemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iW! tN4 net.. than by an,hundred
doll for.500), txubjena the opplicannoacivil penalty of POWER DEVICES, ❑TENANT FOOD SERVICE
Z p. not more than Eve hundred dollars y empl. IMPROVEMENT _
a0 ❑Lo are work,
,and
property,remyemntended with wages rsalei(Sec. 044,8 Busineon,ss
SWIMMING POOL ELECTRIC
andwill dothework,Cod Ne structure iatnot r's License
Law does of apply to
Boniness - ❑OTHER
end Professions Code:The Contractor's License Law does not apply to owner of OUTLETS-SWITCHES-FlXTURES
a' property who builds or improves thereon,and who does such work intended
ohimself or through
his own employees,re provided that such mens is
seold within rre not intended m pllrered for NEW RESIDENTIAL ELECTR SQ FT. V
owneLhowevenllhave the b rden of vement ithat hedon buildyear of
or improve for
C' r SQ.F]'(, f70ft AREA LSQ.FT.
caner-builder will have the burden of proving that he did not build or improve fm par G"• a`'C�CT
pose o[sme). - - a4
1,as owner of the propcny,zm exclusively contracting with licensed contractors m TOTAL: �A ;1h
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- Y y`
scale Law does not apply to an owner of praperty who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who coaermor for such projects with acommutorhOlicensed pursuanro the Contractors
License Law, PERMIT ISSUANCE
❑Iamexemptonder Sec. ,B&PCfor Nis mason r��y•
Owner Date ALTER-DRAIN&VENT-WATER(EA,) VALUATjQy�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Y�j /y-/•C,1 CJ''c'�
❑ 1 hereby affirm under penalty of perjury one of the following dmlamtiana:
I have and will maintain a Certificate ofComeno to self-inswe for Worker's Compen- DRAINS-FLOOR.ROOF AREA.6NDA STORIES TYPE CONSTRUCTION
section,as provided for by Section 3700 of the Labor Castle.for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
C I have and will maintain Workers Compensation Insurance,as required by Section '
37M of the Lubin Coq(ar, Ne perfomnrnre of the work for which IN,permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Work masntion mmntt 'entad%licy nophrrar4 rll GAS-G.SVSTEM-OVER4fEA)
Cartier. 6 Policy No:^ V 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed if thee,permit is for one bundled dollars(5100) BUILDING DIVISION TEES
err less.) I GREASF.TRAP PLANCHECK FEE
I nearly that in are performance ofthe workfor which this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner sous to become subject to the Workers'Compen- ENERGY FEE
O-Z section laws of California.Dare WATER HEATER W/VENT/ELECR
7 0 Applicant GRADING FEE
a rj1 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
a ; became subject to are Workers Compensation provisions of the labor Cade,you must SOILS FEB
forthwith comply with such provisions or this permit shall he dcemcd revoked. WATER SERVICE
0
CONSem isaONLENnlNG AGENCY NEW RESIDENTIAL PLMB. SQ.FT, PAID
L)0 l herebydfum that there issued((Sec.
construction0 lending agency for the peRormance of Data Receipt
0 �•+ the work for which this permit is issued(Sec.1097,Ci,C.)
0 U Landers Name TOTAL:
WLenders Address TOTAL:
0. 1 certify that 1 have read this application and slam that Ne move information is BUILDING FEE J
C41 correct.l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL.PERMIT FEE
G building conswcum and h mbyauthodzcmpmsenutivesofthiscity menterupon are SEISMIC FEE o g.
above-mentioned propcvy for inspection purpose. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
[lab ilities,judgme ,costs and exp s=h'ich may in any way accmeagmast said City ALTER OR ADD TO MECH.
inconuquettce the granting o(this permit PLUMBING FEE
APPLICANT .NDERST NOS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000 CFM)
SOURCE 'ULATION MECHANICAL FEE
FAII AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
reofAppiican ommcDC EXHAUST HOODfW/DUCfI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willy me Cupenlmfduni buildings.Chaptmorem handle Health
and Safely HEATING UNIT(TO IW,tXI)BTU)
CS defined by Ne Cupertino Municipal Cade,Chapter 9.12,and the Ncanh and Safety
Code,Secuon S532(a)7 - HEATING UNIT(OVER I(O,000 B'I'U)
❑Yes ( VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occuoccupantuse equipment or devices which Data Receipt a
emit luzardous air contaminants as defam y the Bay Arca Air Quality Management BOILER-COMP IMP OR 100,000 BTU)
DisuinTOTAL:
❑Yes? BOILER-COMP(OVER 1/0,000 B-ru)
I have regulate bmallous materials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
forma Health& fety Code,Sections 25505.M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoes cturenoly am Lane iyyyyyys my responsibilityto naify Ne occupant
of Ne TI cots whi rr)!tp' ssumtce ofa Cenif at f0 t Y. 's
07
age—
c or authorise agent Date TOTAL: ISSUEDB
OFFICE